Nursing Home Resident Dies after Staff Member Fails to Administer CPR

An inspection report in July 2013 by the New York State Department of Health (DOH) revealed that a resident of Hornell Gardens, a 114-bed nursing facility located in Hornell, New York, died after a licensed practical nurse (LPN) failed to administer CPR after the resident was found without a pulse and was “gasping for air.” According to DOH investigators, the resident, who suffered from multiple sclerosis, did not have a do-not-resuscitate (DNR) order in place. However, in March 2013, when an LPN found the resident without a pulse, the nurse failed to perform CPR even though a defibrillator was located on a nearby cart. When 911 emergency personnel arrived, they began to administer life-saving measures on the resident; the patient died a short time later. When asked about the incident, the director of nursing for the facility stated that “CPR should have been started for this resident.”

The DOH investigation further revealed that the nursing home did not have an adequate system in place to identify whether or not a resident had a DNR order. Residents who want to be resuscitated in an emergency are supposed to wear a white bracelet, while residents who do not want to be resuscitated are supposed to wear a blue bracelet. During the inspection, DOH investigators discovered 15 residents who were not wearing any bracelets or who were wearing bracelets that were the wrong color. For instance, one resident who was suffering from a hip fracture and dementia was wearing a blue bracelet, indicating that the resident had a DNR in place. Upon further review of the patient’s records, investigators discovered that the resident did not have a DNR and wanted to be given CPR in an emergency. When asked about the error, the nurse in charge of verifying the residents’ bracelets stated that she “did not know why she missed this resident.” The DOH stated that this situation was widespread and placed residents at serious risk of harm.

DOH investigators also cited the facility for failing to properly dispense medications. One resident suffering from hypertension was prescribed a heart medication. According to the physician’s orders, staff members were required to stop administering the medication if the resident’s blood pressure fell below a certain level. Over a period of several weeks, nurses did not administer the medication on eight separate occasions because the patient’s blood pressure had dropped below the indicated threshold level. However, the physician was never notified of the situation in order to assess the patient’s medication regimen. The DOH concluded that, “This is a repeat deficiency from the recertification surveys of 5/25/12 and 5/12/11.” The report also concluded that, “The facility continues with the same problem with the same cardiac medication.”

According to the “Nursing Home Compare” website, Hornell Gardens received an overall rating of below average. The facility’s health inspection record was considered to be much below average.